Judge Sets Deadline For HHS To Clean Up Medicare Appeals Backlog Pileup

Wednesday, November 28, 2018
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On November 2, 2018, a federal judge in Washington, D.C. said the U.S. Department of Health and Human Services (HHS) has until the end of 2022 to completely clear out its backlog of thousands of Medicare billing appeals.  This decision is the latest in a long line of litigation launched by the American Hospital Association and others that has dragged on for years.

The problem stems from the fact that hospitals, physicians, medical groups, podiatrists, home health agencies and other Medicare providers are often targeted by Medicare "headhunters" such as Zone Program Integrity Contractors (ZPIC), and Recovery Audit Contractors, who are incentivized to audit and disallow as many claims as possible.  Then when the Medicare provider attempts to appeal utilizing the Medicare Appeals Process, the delays are unconscionable.  One court described the process as "byzantine." Even when the provider finally gets to the stage of being authorized to request a hearing, there has been a delay in even beginning the processing of the hearing request of over two years.  By the time a hearing can be conducted, often the provider is out of business, unless it is a major institution with major financial resources.  Furthermore, HHS is, apparently, free to have the Medicare Appeals Council send the case back for a new hearing, again and again, if it disagrees with the results.  This is another way of unconscionably dragging the case out and exhausting the Medicare provider's financial resources.

We have had Medicare providers who had received initial audit results finding 100% of their claims were improper.  Upon appeal, they received 100% reversal with findings that all of their claims were completely proper.  We have another client, a home health agency, who has had its case involved in the Medicare Appeals Process for over ten (10) years.  It has been before a HHS Administrative Law Judge three (3) times;  the Medicare contractors involved have refused to honor the administrative law judge's decision.


Government Funding.

Despite receiving funding to address the backlog of thousands of Medicare billing appeals, HHS  originally said the job couldn’t be done without more money from Congress or cooperation from providers. Click here to learn more.  Therefore, Congress agreed to give HHS $182.3 million more. HHS itself projected that it would be able to totally eliminate the backlog by 2022. This argument has been ongoing with litigation for years now.


Financial Strain on Hospitals.

Hospitals claim they faced financial ruin after waiting years for HHS to take care of millions in Medicare claim appeals and have been waiting for some sort of repayment. In 2017, the district court imposed deadlines on HHS, yet the D.C. Circuit, again tossed the decision, saying the lower court hadn’t “specifically made a finding that it was possible for the secretary to comply with the order.” Click here to learn more about the ongoing suit.

HHS said in a statement it was looking into the court’s decision and is working on meeting the agency’s “own projections for eliminating the backlog and comply[ing] fully with the court’s order.”

Click here to read the Memorandom & Opinion in full. 

To read the previous blog I wrote on this case, click here.

Of course, it's always the big boys, the hospitals, who are able to get attention for the problems that affect them.  The small providers, individual physicians and small home health agencies who do not have the same financial resources and lobbyists, just get put completely out of business.  This ruins lives and families and deprives communities of jobs.


Contact Health Law Attorneys Experienced in Handling Medicare Audits, ZPIC audits, RAC audits, Medicare Administrative Hearings, ALJ hearings, Medicare Appeals, Investigations and other Legal Proceedings.

The Health Law Firm’s attorneys routinely represent physicians, dentists, orthodontists, medical groups, clinics, pharmacies, assisted living facilities (AFLs), home health care agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.


Sources:

Lidgett, Adam. “Timeline Set For HHS To Clean Up Medicare Appeals Backlog.” Law360.
(November 2, 2018). Web.

Minemyer, Paige. “Judge sets timetable for HHS to clear its Medicare appeals backlog.” Fierce Healthcare.com. (November 1, 2018). Web.


About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

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11/28/2018

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